Comprehensive Psychiatry 85 (2018) 55–60

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Comprehensive Psychiatry

journal homepage: www.elsevier.com/locate/comppsych

Impaired neuropsychological profile in homicide offenders

with schizophrenia
Katharina Nymo Engelstad a,⁎, Anja Vaskinn b,c, Anne-Kari Torgalsbøen d, Christine Mohn a,
Bjørn Lau d,e, Bjørn Rishovd Rund a,d
a
Research Department, Vestre Viken Hospital Trust, P. O. Box 800, 3004 Drammen, Norway
b
NORMENT K. G. Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, Oslo University Hospital, P. O. Box 4956, Nydalen, 0424 Oslo, Norway
c
Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, P. O. Box 1039, Blindern, 0315 Oslo, Norway
d
Department of Psychology, Faculty of Social Sciences, University of Oslo, P. O. Box 1094, Blindern, 0317 Oslo, Norway
e
Lovisenberg Diaconal Hospital, P. O. Box 4970, Nydalen, 0440 Oslo, Norway

a r t i c l e i n f o a b s t r a c t

Background: Our ability to predict and prevent homicides committed by individuals with schizophrenia is limited.
Cognitive impairments are associated with poorer functional outcome in schizophrenia, possibly also homicide.
The aim of the current study was to investigate global and specific cognition among homicide offenders with
schizophrenia (HOS).
Methods: Twenty-six HOS were compared to 28 individuals with schizophrenia and no history of violence (non-
HOS), and a group of healthy controls (HC, n = 151). HOS and non-HOS participants were recruited from in- and
outpatient units across Norway. An extensive neuropsychological test battery was administered.
Results: HOS participants performed significantly weaker than HC in all cognitive domains. Further, statistically
significant differences between HOS and non-HOS participants were found for IQ (d = 0.52) and verbal learning
(d = 0.82), with larger impairments in the HOS compared to the non-HOS group.
Conclusions: Our results indicate that HOS participants show clinically significant impairments in global and spe-
cific cognition.
© 2018 Elsevier Inc. All rights reserved.

1. Introduction
1.1. Schizophrenia, violence and homicide
A diagnosis of schizophrenia is associated with an increased risk of
committing homicide, it is estimated that individuals with this diagno-
sis commit 6% of all homicides [1]. The percentage is higher, probably
about 20%, in jurisdictions with low homicide rates such as the Scandi-
navian countries [2].
A meta-analysis of 110 studies investigating risk factors of violence
in psychosis concluded that hostile behaviour, non-adherence to psy-
chotherapy, recent drug and alcohol abuse, non-adherence to medica-
tion, as well as a history of criminal behaviour were the strongest
predictors [3].
⁎ Corresponding author at: Research Department, Vestre Viken Hospital Trust, P. O. Box
800, 3004 Drammen, Norway.
E-mail addresses: k.n.engelstad@psykologi.uio.no (K.N. Engelstad),
anja.vaskinn@medisin.uio.no (A. Vaskinn), a.k.torgalsboen@psykologi.uio.no
(A.-K. Torgalsbøen), h.c.mohn@psykologi.uio.no (C. Mohn), bjorn.lau@psykologi.uio.no
(B. Lau), b.r.rund@psykologi.uio.no (B.R. Rund).
Although several risk factors for violence have been detected, cur-
rent risk assessment tools are limited with regards to predicting vio-
lence in general [4], and specifically in schizophrenia [5]. Adding new
factors that are of importance to violence in such risk assessment tools
could aid violence prediction. Increased knowledge of the characteris-
tics of individuals with a diagnosis of schizophrenia who commit severe
violence is a step in the direction of improving current violence risk as-
sessment tools.
1.2. Is cognitive deficit a risk factor for violence in schizophrenia?
Cognitive impairment is a defining feature of [6,7] and associated
with functioning [8,9] in schizophrenia. Severe interpersonal violence,
such as homicide, is an example of very poor functional outcome.
From this follows that impaired cognition may be a predictor of homi-
cide in individuals with schizophrenia. A proposition of lower general
intelligence (IQ) as a potential risk factor of violence was made decades
ago, although this was a study of violence in criminal offenders and not
specifically individuals with schizophrenia [10].
Recent research has yielded optimism when it comes to the inclu-
sion of cognitive factors in future violence risk assessment tools

https://doi.org/10.1016/j.comppsych.2018.06.002
0010-440X/© 2018 Elsevier Inc. All rights reserved.
56 K.N. Engelstad et al. / Comprehensive Psychiatry 85 (2018) 55–60
[11,12]. A study of 25 homicide offenders with schizophrenia (HOS) [12]
found impairments in a measure of general IQ. The researchers also
found impairments in specific cognitive domains, including speed of
processing, visuoconstructional abilities and a test of reasoning. A fol-
low-up study of the same HOS included a control group of participants
with schizophrenia who did not have a history of violence (non-HOS)
[13]. The results indicated that HOS had relatively larger impairments
than non-HOS in a measure general IQ, memory and executive function-
ing. IQ as a possible predictor of inpatient violence has also been sug-
gested by Fullam and Dolan [14], who found lower IQ scores among
violent than non-violent participants. In a recent review of the literature
on violence and neuropsychological function in schizophrenia,
Sedgwick, Young, Baumeister, Greer, Das and Kumari [15] concluded
that there was evidence for an association between lower IQ, memory
and executive function and violence in schizophrenia.
While some studies find a more pronounced generalized deficit in
violent than in non-violent schizophrenia, others have focused on spe-
cific cognitive domains. A few studies [16–18], but not all [14], have
found that poor executive function is associated with increased violence
risk. Another study by Corbett, Karyadi, Kinney, Nitch, Bayan and Wil-
liams [19] found reduced verbal learning abilities among forensic inpa-
tients with schizophrenia spectrum disorders, with scores about 1.5
standard deviations below the normative mean.
There are several limitations to the existing literature. First, as point-
ed out by Fullam and Dolan [14], definitions of violence are heteroge-
neous. While Stratton, Brook and Hanlon [12] focused solely on
homicide, Brugman, Lobbestael, von Borries, Bulten, Cima, Schuhmann
et al. [11] investigated verbal and physical violence collapsed. Second,
we cannot draw inferences about violence risk in schizophrenia from
studies of criminal offenders without mental illness [10,16]. Third, cog-
nitive deficit as a risk factor for violence in schizophrenia has often been
investigated with few tests [11,19], although there are exceptions
[13,15,17,20]. O'Reilly, Donohoe, Coyle, O'Sullivan, Rowe, Losty et al.
[20] applied the Measurement and Treatment Research to Improve Cog-
nition in Schizophrenia (MATRICS) Consensus Cogntive Battery (MCCB)
in a study of a forensic population with schizophrenia. They found that
neurocognition and social cognition predicted inpatient violence over a
12 month follow-up period. Social cognition and neurocognition
accounted for 34% of the variance in violence after controlling for age
and gender. However, both those who committed violence during the
follow-up period and those who did not had a history of violence prior
to being admitted to the forensic hospital. Possibly, institutional vio-
lence could have other causes than non-institutional violence, suggest-
ing that situational factors can be particularly important in institutional
violence [21].
Table 1
Demography and clinical data.
HOS, n = 26
Age 38.2 (7.3)
Sex, male⁎⁎ 25 (96%)
Education, years⁎⁎ 9.6 (2.2)
Diagnosis 23 schizophrenia
3 schizoaffective
Illness duration, years 15.7 (6.7)
Medication, DDD⁎, b 1.84 (0.80)
Time since offense, years 6.5
Norwegian native language⁎ 15 (57.7%)
Inpatients⁎⁎ 16 (61.5%)
PANSS positive (min–max 4–28) 7.2 (4.1)
PANSS negative (min–max 6–42) 10.2 (5.2)
PANSS disorganized (min–max 3–21) 5.7 (2.0)
PANSS excited (min–max 4–28)⁎⁎ 5.1 (1.5)
PANSS depressed (min–max 3–21) 6.3 (3.6)
a
N = 27.
b
DDD = defined daily dose [23].
⁎ p b .05.
⁎⁎ p b .01.
In the current study, some of the challenges presented above are ad-
dressed through an extensive investigation of cognition and homicide in
schizophrenia. Specifically, we will explore cognitive characteristics
among those who have a diagnosis of schizophrenia that have commit-
ted homicide. We ask if HOS participants show global cognitive impair-
ments compared to non-HOS and healthy controls (HC). In addition, we
will examine if HOS participants show specific cognitive impairments in
the executive functioning and verbal learning domains.
2. Material and methods
2.1. Participants
The HOS study is a cross-sectional comparative study. It was con-
ducted at Vestre Viken Hospital Trust in Norway, in collaboration with
a number of in- and outpatient units across the whole country. Data
were collected by the first author between October 2015 and June 2017.
Participants were two groups of individuals with a diagnosis of
schizophrenia or schizoaffective disorder (Table 1). Twenty-six of
them were sentenced to compulsory mental care for homicide or homi-
cide attempt (HOS group), and 28 had no history of interpersonal vio-
lence (non-HOS group). Diagnostic evaluations were made by
clinicians at collaborating units prior to inclusion in the current study
and were based on the International Statistical Classification of Diseases
and Related Health Problems (ICD-10) [22]. Participants were excluded
if they had insufficient knowledge of Norwegian language, i.e. were un-
able to undergo clinical interviews and cognitive testing in Norwegian.
Norwegian language skills were evaluated qualitatively before the
participant signed informed consent. One HOS who was eligible for
participation was excluded due to insufficient comprehension of
Norwegian.
At the time of inclusion, all participants received antipsychotic med-
ication (Table 1). Medication Defined Daily Dose (DDD) was calculated
for each participant according to World Health Organization (WHO)
guidelines [23]. Information on participants' background, including ill-
ness history and violent episodes (HOS group), was available from med-
ical records and participants' treating clinicians.
To maximize the number of eligible participants for the HOS group,
patients were recruited regardless of time since the violent offense.
Both participants who had committed homicide and homicide attempt
were included in the HOS group, because it is often arbitrary or circum-
stantial whether a severely violent act towards another person is lethal
or not.
Participants were initially informed of the study by their treating cli-
nician, and received further information by the first author upon
Non-HOS, n = 28 HC, n = 151
36.7 (10.1) 34.1 (8.9)
25 (89%) 76 (50%)
11.1 (1.6) 12.9 (2.5)
25 schizophrenia –
1 schizoaffective
13.7 (10.1)a –
1.36 (0.64) –
– –
24 (85.7%) –
3 (10.7%) –
7.5 (4.7) –
8.1 (2.8) –
4.8 (1.7) –
4.2 (0.5) –
7.0 (2.8) –
 K.N. Engelstad et al. / Comprehensive Psychiatry 85 (2018) 55–60 57

acceptance. All participants gave written informed consent prior to as-
sessments. The study was approved by the Regional Committee for
Medical and Health Research Ethics (REC South East 2015/713).
The healthy control group (HC) were 151 individuals who partici-
pated in the Norwegian MCCB standardization study [24]. Participants
in the standardization study did not have a history of severe mental ill-
ness, substance abuse or severe head trauma. They also had sufficient
knowledge of Norwegian language to undergo tests in Norwegian. For
an extensive description of exclusion criteria of the Norwegian MCCB
reference study, see Mohn, Sundet and Rund [24].
2.2. Measures
2.2.1. Symptom measure
Symptoms were assessed with the Positive and Negative Syndrome
Scale (PANSS) [25]. Symptom levels are shown in Table 1. Scores are
based on a validated five factor PANSS model, and includes positive,
negative, disorganized, excited and depressed symptoms [26,27].
2.2.2. Measures of cognition
Global cognition was assessed with the 2-subtest version of the
Wechsler Abbreviated Scale of Intelligence (WASI) [28], consisting of
the Vocabulary and Matrix Reasoning subtests. A composite score de-
rived from the MCCB norms [29] also indexed global cognition.
Specific cognitive functioning was examined with a number of neu-
ropsychological tests (Table 2). The MCCB [29] comprises seven cogni-
tive domains assessed with ten different tests: Speed of processing;
Trail Making Test – Part A (TMT-A), Brief Assessment of Cognition in
Schizophrenia (BACS) Symbol Coding and Category Fluency: Animal
Naming. Attention/vigilance; Continuous Performance Test – Identical
Pairs. Working memory; Wechsler Memory Scale – third edition
(WMS-III) Spatial Span and Letter-Number Span (LNS). Verbal learning;
Hopkins Verbal Learning Test – Revised (HVLT-R). Visual learning; Brief
Visuospatial Memory Test – Revised (BVMT-R). Reasoning/problem
solving; Neuropsychological Assessment Battery (NAB): Mazes. Social
cognition; Mayer-Salovey-Caruso Emotional Intelligence Test
(MSCEIT): Managing Emotions. Standard scores were calculated for
each domain based on age- and gender corrected US norms.
Two studies investigating the psychometric properties of the Nor-
wegian translation of the MCCB showed that the translated version
was sensitive to the cognitive deficits shown by patients with schizo-
phrenia compared to healthy controls, in all domains covered by the
test battery, except from the MSCEIT test [30,31].
Because the MCCB does not extensively target executive functions,
we added the Delis-Kaplan Executive Function System (D-KEFS)
Color-Word Interference Test (CWIT) to our test battery [32]. The
CWIT consists of four conditions where the first two conditions measure
basic abilities, colour naming and reading colour names. The third and
fourth conditions, inhibition and inhibition/switching, challenge execu-
tive abilities. A standard score for each condition derived from age
corrected norms was used in the analyses.
2.3. Statistics
All statistical analyses were performed using The Statistical Package for
the Social Sciences (IBM SPSS Statistics for Windows, version 24.0) [33].

Table 2
Cognition among HOS, non-HOS and HC, results of ANOVAs.

HOS (n = 26) Non-HOS (n = 28) HC (n = 151) Statistic Partial eta squareda Cohen's db
c d
WASI IQ 87.0 (16.7) 98.0 (15.8) 108.5 (14.3) F(2, 198) = 26.2 0.21 0.68
p b .01
WASI Vocabularye 38.3 (12.4) 45.9 (12.1) 50.8 (8.9) F(2, 200) = 18.9 0.16 0.62
p b .01
WASI Matrix Reasoninge 43.8 (12.6) 50.4 (13.2) 57.6 (7.7) F(2, 199) = 27.9 0.22 0.51
p b .01
e
MCCB comp 27.4 (8.2) 32.0 (9.3) 47.1 (8.3) F(2, 202) = 85.8 0.46 0.52
p b .01

MCCB domainse
Speed of processing 29.9 (9.2) 32.2 (9.3) 49.0 (9.7) F(2, 202) = 69.5 0.41 0.25
p b .01
Working memory 33.5 (10.4) 37.3 (11.8) 44.5 (8.1) F(2, 202) = 21.0 0.17 0.34
p b .01
Verbal learning 34.5 (4.2) 40.5 (10.5) 47.3 (9.3) F(2, 202) = 26.1 0.21 0.75
p b .01
Visual learning 37.2 (13.2) 39.3 (13.9) 51.4 (8.6) F(2, 202) = 33.6 0.25 0.15
p b .01
Attention/vigilance 32.5 (10.0) 33.1 (8.2) 45.5 (8.0) F(2, 202) = 46.5 0.32 0.07
p b .01
Reasoning/probl. solv. 37.9 (8.0) 41.2 (8.6) 49.6 (9.5) F(2, 202) = 23.9 0.19 0.40
p b .01
Social cognition 33.3 (12.2) 37.9 (11.1) 49.6 (10.3) F(2, 202) = 35.3 0.26 0.39
p b .01

CWITf
Colour naming 5.3 (3.3) 5.7 (3.4) – F(1,52) = 0.17 0.003 0.12
p = .69
Word reading 7.7 (2.7) 8.5 (5.0) – F(1,52) = 0.62 0.01 0.20
p = .44
Inhibition 6.7 (3.6) 7.0 (3.8) – F(1,52) = 0.14 0.003 0.08
p = .71
Inhibition/switching 7.2 (3.2) 7.9 (3.4) – F(1,52) = 0.61 0.01 0.21
p = .44
a
Partial eta squared for three groups.
b
Cohen's d for HOS and non-HOS groups.
c
IQ scores: M = 100, SD = 15.
d
N = 147.
e
T-scores: M = 50, SD = 10.
f
Scaled scores: M = 10, SD = 3.
58 K.N. Engelstad et al. / Comprehensive Psychiatry 85 (2018) 55–60
Univariate analyses of variance (ANOVAs) were applied to examine
differences in clinical, demographical and cognitive functioning be-
tween the groups. Only the HOS and non-HOS groups were compared
on executive functioning as indexed by the CWIT. The HC group was
added in analyses of global and specific cognition measured with
WASI and MCCB. For analyses that included three groups and that
yielded significant main effects, ANOVAS were followed by post hoc
tests (Tukey) to infer which group differed from the others.
Alpha level was set at 0.05. We decided not to correct for multiple
comparisons because of the small sample size in the HOS and non-
HOS groups and the risk of committing type II errors.
Two different effect sizes are reported (see Table 2). Partial eta
squared was used to describe the overall strength of group differences
in the analyses including the three study groups. In addition, we calcu-
lated effect sizes for the differences between HOS and non-HOS groups
(Cohen's d) using the pooled standard deviation (Table 2).
3. Results
3.1. Global cognition
We detected a significant effect of group membership on IQ level
(Table 2). A follow-up post hoc analysis revealed that HOS participants
had significantly lower IQ scores than both non-HOS and HC partici-
pants. The difference between non-HOS and HC was statistically signif-
icant. The three groups also differed significantly on another global
measure of cognitive functioning, the MCCB composite score (Table 2,
Fig. 1). A post-hoc test indicated that the significant group difference
was driven mainly by the discrepancy between HC and the two schizo-
phrenia (SZ) groups. The non-HOS group performed better than HOS
participants, although this difference did not reach statistical
significance.
3.2. Specific cognitive functions
Follow-up analyses yielded similar results: The groups differed sig-
nificantly on all MCCB cognitive subdomains (Table 2, Fig. 1). For all do-
mains, except verbal learning, the significance was driven by HC
outperforming both clinical groups. There were no significant differ-
ences between HOS and non-HOS groups. However, for the verbal
learning domain, the difference between the SZ groups was significant.
For this domain, HOS had lower scores than non-HOS.
Fig. 1. MCCB results across cognitive domains. Average T-scores. M = 50, SD = 10.
Univariate analyses of variance for the four CWIT subtests measuring
executive function (Table 2) revealed no significant differences be-
tween HOS and non-HOS for any condition.
3.3. Follow-up analyses
Because there were significantly more participants in the HOS than
in the non-HOS group that were not native Norwegian speakers, we re-
peated the analyses that had yielded significant differences between the
HOS and non-HOS group on only native speaking participants. HOS par-
ticipants were still outperformed by the non-HOS group. The effect sizes
for the IQ measure was medium sized, (d = 0.52), but the difference
was no longer statistically significant (F(1, 37) = 2.45, p = .13). For the
verbal learning domain the group difference between HOS and non-
HOS participants remained statistically significant (F(1, 37) = 5.25, p =
.03), and the effect size was large (d = 0.82).
4. Discussion
In this study, we compared two groups of participants with schizo-
phrenia, one that had committed homicide or homicide attempt and
one that had not committed interpersonal violence, to a group of
healthy controls. Our aim was to examine the cognitive characteristics
of HOS using a standardized, extensive, cognitive test battery. We
asked if HOS participants showed global cognitive deficits, as well as
specific deficits in the verbal learning and executive functioning
domains.
4.1. Global cognition
First, we found large IQ differences between the groups, with mean
IQ scores of 87, 98 and 109 for the HOS, non-HOS and HC respectively.
Individuals with schizophrenia have, on average, lower IQ than non-af-
fected peers, and low IQ may be an intrinsic risk factor for later develop-
ment of schizophrenia [34]. However, HOS participants had, on average,
an IQ score 12 points below non-HOS. The difference between HOS and
non-HOS thereby approached one standard deviation, whereas the dif-
ference between HOS and HC amounted to more than 1.5 standard de-
viation. This is in line with the findings of Stratton, Brook and Hanlon
[12] whose HOS participants had an average IQ of 79.
Attempts to disentangle mechanisms behind the lower IQ among
HOS participants in the present study would be mere speculation,
 K.N. Engelstad et al. / Comprehensive Psychiatry 85 (2018) 55–60
although some researchers have pointed to associations between IQ, vi-
olence, trauma and schizophrenia. Meta-analytic findings by Ttofi,
Farrington, Piquero, Lösel, DeLisi and Murray [35] indicated that high in-
telligence was a possible protective factor against criminal offending.
Another study by Oakley, Harris, Fahy, Murphy and Picchioni [36] point-
ed out that exposure to violence in childhood could be a causal factor for
later violent offences in schizophrenia. Possibly, as hypothesized by
Koenen, Moffitt, Caspi, Taylor and Purcell [37], childhood trauma
could have an impact on neurodevelopment and thereby be a causal fac-
tor of lower IQ. Further research on these associations is needed to war-
rant relevance for the current sample.
A second finding was the significant differences on the MCCB cogni-
tive composite score, with HC performing significantly better than HOS
and non-HOS. Non-HOS participants performed better than HOS partic-
ipants, but this difference did not reach statistical significance.
4.2. The MCCB cognitive subdomains
Exploration of the seven cognitive subdomains of the MCCB showed
a consistent pattern of performance, with HC performing significantly
better than both non-HOS and HOS participants in all domains. Non-
HOS had higher mean scores than HOS in all cognitive domains, but
the difference reached statistical significance only for verbal learning.
Effect sizes for the difference between HOS and non-HOS were however
approaching medium magnitude for the working memory, reasoning
and social cognitive domains, while the effect size for the verbal learn-
ing domain was large.
HOS participants performed two standard deviations below HC in
the verbal learning and social cognitive domains, while the difference
was more than one standard deviation for the remaining domains. So-
cial cognition was indexed by the MSCEIT test in this study, a test that
has not been able to detect social cognitive deficits in all schizophrenia
samples [31]. Future studies that investigate a broader array of social
cognitive functions, using more sensitive tests, could inform us further
of the nature of social cognitive impairments among HOS.
4.3. Executive function
Exploration of executive functions among HOS and non-HOS using
the CWIT revealed no significant differences between groups. Results
for each of the four conditions were almost similar in both groups. Al-
though previously found in some studies [16–18], we did not detect dif-
ferences in executive functioning in our sample. However, neither
Barkataki, Kumari, Das, Hill, Morris, O'Connell et al. [17] nor Enticott,
Ogloff, Bradshaw and Fitzgerald [18] found differences between violent
and non-violent offenders with schizophrenia on measures of inhibition
(Stroop-like tasks). Meijers, Harte, Meynen and Cuijpers [16] did find
such differences, but they did not investigate participants with schizo-
phrenia. As suggested by Enticott, Ogloff, Bradshaw and Fitzgerald
[18], these results could indicate that cognitive inhibition may be differ-
ently related to impulsivity in schizophrenia and non-schizophrenia
populations.
4.4. Clinical implications
We found that HOS participants performed significantly weaker
than both non-HOS and HC in the verbal learning domain, which was
indexed by the HVLT – R. HOS performed about 1.5 standard deviations
below the normative mean. This deviation is in the same range as a
study by Corbett, Karyadi, Kinney, Nitch, Bayan and Williams [19], and
the authors point to the potential negative consequences of verbal
learning impairments, because most of the non-pharmacological treat-
ments are based on talking. In addition, verbal learning was previously
found to be one of the cognitive domains that is most consistently asso-
ciated with different aspects of functional outcome, and “it appears that
verbal memory and vigilance are critical prerequisite capacities for skill
59
acquisition in psychosocial rehabilitation programs” (Green [38],
p. 325). Our results could indicate that particular caution should be
taken in treatment and rehabilitation of violent patients with schizo-
phrenia to ensure that verbal learning impairments are not an obstacle
for the patient to learn and understand information relevant for the re-
habilitation process.
Previous studies such as Simonsen, Sundet, Vaskinn, Ueland, Romm,
Hellvin et al. [39] have defined clinically significant impairments as
scores 1.5 standard deviations below normative mean. Concerning the
current study, the HOS group performed 1.5 standard deviation below
normative mean on several measures. Following this approach, clinical-
ly significant impairments were found in both global cognition (MCCB
composite), and several specific cognitive domains (speed of process-
ing, working memory, verbal learning, attention/vigilance and social
cognition). For the remaining results (IQ, visual learning and reason-
ing/problem solving), performance of the HOS group approached 1.5
standard deviations below normative mean. Although not all differ-
ences in cognitive functioning between non-HOS and HOS participants
reached statistical significance, we believe the relatively large impair-
ments shown by the HOS group compared to a normative mean have
clinical implications. These deficits would be expected to have substan-
tial functional consequences.
In this study we have investigated neuropsychological characteris-
tics of HOS independent of other potentially important covariates such
as substance abuse, trauma exposure, or other factors that could con-
tribute to increased homicide risk in interaction with neuropsychologi-
cal functioning. Large, Smith and Nielssen [1] also present the role of
lower socio-economic status, and the effect of migration, and how this
affects treatment access, as potential factors to investigate in association
with homicide and schizophrenia. These topics are beyond the scope of
the current study, but further examination in a larger HOS sample could
contribute to improving violence risk assessment for this group.
4.5. Strengths and limitations
Strengths of the study include clearly defined groups when it comes
to history of violence, as well as a healthy control group. The application
of a comprehensive neuropsychological test battery developed specifi-
cally for schizophrenia is another advantage. It is estimated that 80 peo-
ple are currently sentenced to compulsory mental care for homicide or
homicide attempt in Norway [40]. We have collected information on
26 HOS, which equalizes as much as 32.5% of the relevant population.
Participants were recruited from both rural and urban areas across the
country, and we therefore believe our HOS group is representative of
the HOS population in Norway.
Some limitations should however be taken into consideration. Al-
though we have included a substantial percentage of the HOS popula-
tion in Norway, our HOS sample remains quite small. The cross-
sectional design means that there is a temporal gap between violent of-
fense and inclusion in the study, for some of our variables of interest this
time gap could have an impact on the results.
A general critique of studies investigating associations with violence
is that we cannot rule out that our results are not specifically indicators
of violence risk, but a more general tendency towards antisocial behav-
iour [4]. It is possible that weaker cognitive performance among HOS
participants than non-HOS participants is not associated with HOS hav-
ing committed violence but having shown criminal or anti-social ten-
dencies in a broader sense.
Significantly more HOS than non-HOS participants did not speak
Norwegian as their native language, which may have influenced our re-
sults. We have, however, qualitatively evaluated the validity of each
participant's test results. Additionally, we conducted ANOVAS compar-
ing only HOS and non-HOS participants whose native language was
Norwegian. The pattern of the results remained mainly the same.
Based on the qualitative evaluations and follow-up analyses, we find it
60 K.N. Engelstad et al. / Comprehensive Psychiatry 85 (2018) 55–60
most likely that our results are not explained by differences in native
language.
The inclusion of a measure of pre-morbid IQ would have given more
substance to the interpretation of differing IQ scores in the HOS and
non-HOS groups, particularly because of relatively long illness duration
for both patient groups, as well as a time gap since their violent offense
for the HOS group.
We found that HOS participants received significantly higher doses
of antipsychotic medication than non-HOS (Table 1). This is not surpris-
ing, considering the treatment regimen for this group, where the control
of psychotic symptoms is of primary importance. We cannot rule out
the possibility that this has affected our results. However, we feel confi-
dent that, in this case, the higher antipsychotic medication dose is a re-
flection of the severity of the disorder which also shows itself in larger
neuropsychological impairments. Also, our results align with some pre-
vious studies that did not find significant associations between medica-
tion and cognitive functioning [41, 42].
5. Conclusions
In this study we explored cognitive characteristics of HOS, assessing
both global and specific cognition.
Main findings indicate that HOS had significantly lower IQ scores
than the non-HOS group. Non-HOS also outperformed HOS on the
MCCB, although the difference reached statistically significance only
for the verbal learning domain. HC performed significantly better than
both non-HOS and HOS on global cognition as well as in all MCCB cog-
nitive subdomains.
Role of the funding source
The study was funded by Vestre Viken Hospital Trust, grant number
9603009. The funding source had no role in study design, data collection
and analysis, decision to publish or preparation of the manuscript.
Declarations of interest
None.
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